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Vicarious Trauma,
Secondary Traumatic Stress
and Burnout
Ana M. Storey
Managing Attorney, West Office
Legal Aid Foundation of Los Angeles
Alisa Neary, MSW, LCSW
Project Manager / Senior Social Worker
Legal Aid Foundation of Los Angeles
Outline
What is meant by Vicarious Trauma (VT),
Secondary Traumatic Stress (STS) and Burnout?
Why does this concern legal services?
What are the symptoms?
Treatment and prevention
ALISA
Vicarious Trauma
Vicarious Trauma (VT) is the cognitive shift in
beliefs and thinking experienced by
professionals as a result of empathic
engagement with trauma survivors.
Examples of these cognitive shifts in beliefs
and thinking include: Alterations to one’s sense of self
Changes in world views about issues like safety, trust and
control
Changes in spiritual beliefs
McCann, I. L. & Pearlman, L. A., (1990) Vicarious Traumatization: A Framework for Understanding the Psychological Effects of Working with Victims. Journal of Traumatic Stress, 3, 131-149.
ALISA
Secondary Traumatic Stress
Secondary Traumatic Stress (STS) is the natural behaviors and emotions resulting from exposure to traumatic material and the stress resulting from helping or wanting to help a traumatized or suffering person. This is very similar to Post Traumatic Stress Disorder (PTSD), but it is experienced as a result of hearing about the trauma rather than experiencing it directly.
Figley, C. R., (1995) Compassion Fatigue: Toward a New Understanding of the Costs of Caring. In B. H. Stamm (Ed.), Secondary Traumatic Stress: Self-Care Issues for Clinicians, Researchers and Educators (pp. 3-28). Brooklandville, MD: Sidran Press.
ALISA
Burnout
Burnout is a psychological syndrome in
response to chronic interpersonal stressors
on the job. Overwhelming emotional and physical exhaustion
Feelings of cynicism and detachment from the job
A sense of ineffectiveness and lack of
accomplishment
Burnout can be associated with a very high workload
or a non-supportive work environment.
ALISA
Devilly, G. J., Wright, R. & Varker, T., Vicarious Trauma, Secondary Traumatic Stress or Simply Burnout? Effect of Trauma Therapy on Mental Health Professionals, Australian and New Zealand Journal of Psychiatry, 2009; 43:373-385
VT & STS vs. Burnout
VT & STS
A traumatic
response to clients’
specific traumatic
material
Change in
psychological and
spiritual well-being
Burnout
A response to
being overloaded,
secondary to
traumatic material
Depletion of
physical and
psychological
resources
ALISA
Why Does this Concern the Legal
Profession?
ANA
Substance Abuse
15-18% of attorneys will have substance abuse
problem vs. 10% of general population.
A study in Washington state found that 18 percent
of lawyers were problem drinkers, a number that is
twice the expected rate.
ANA
Divorce
A 1999 article noted higher rates of divorce
among female lawyers.
ANA
Professional Satisfaction
Over 1/3 of attorneys say they are dissatisfied and
would choose another profession if they could.
ANA
Anxiety
A 1991 North Carolina Bar Association study found
25 percent of lawyers suffered symptoms of
anxiety three or more times a month in the last
year.
ANA
Depression
A 1990 Johns Hopkins study found Lawyers suffer from clinical depression at a rate of almost four times that of the norm.
Law student study showed by late Spring of their first year, 32% of the students were depressed. By the Spring of their third year, that number had risen to 40%.
ANA
Suicide
Attorneys have the highest rates of
depression and suicide of any profession.
From reports of Lawyers Assistance
Programs across the country, it is verifiable
that suicide among male lawyers is
approximately two (2) times more likely
than among men in the general
population.
ANA
Stress & Vicarious Trauma
Studies suggest 51% of lawyers experience stress at higher levels than the “normal” population.1
A survey of attorneys working in family law,
domestic violence, and legal aid criminal defense as well as mental health providers and social service providers working with the mentally ill found that attorneys had higher rates of secondary trauma than the other professionals surveyed.2
1Compassion Fatigue - Because You Care, St. Petersburg Bar Association Magazine, February 2006 2Andrew P. Levin & Scott Greisberg, “Vicarious Trauma in Attorneys,” 24 Pace L. Rev. 245 (Fall 2003)
ANA
Lawyer Distress
Competition in law school and process of learning to “think like a lawyer” are stressful
Pressures individuals to change: conflict between pre-law school values and one’s newly emerging lawyer persona
Come to law school with ethic of care, public interest desires, intrinsic motivations
Choice of changing to fit in or becoming isolated: creates inner conflict, contributes to distress
Susan Swaim Daicoff, Lawyer, Know Thyself (American Psychological Association, 2004)
ANA
Lawyer Distress
A 2010 study conducted of the lawyers and
support staff of the Wisconsin State Public
Defender Office showed that attorneys working
with clients experiencing trauma and who worked
long hours were at high risk of developing
significant secondary trauma and burnout
symptoms.
Andrew P. Levin, MD, Linda Albert, LCSW, Avi Besser, PhD, Deborah Smith, JD, Alex Zelenski, MBA, Stacey Rosenkranz, PhD, and Yuval Neria, PhDf, Secondary Traumatic Stress in Attorneys (The Journal of Nervous and Mental Disease, December 2011)
ANA
Lawyer Distress
External stressors of law practice (time pressures,
workload, competition, economy, office politics,
role conflicts, adversary system)
Individual differences make some more
vulnerable to external stressors (flexibility, self-
control, hostility, self-esteem, values, race,
gender)
Amiram Elwork, Stress Management for Lawyers (Vorkell Group, 1995)
ANA
Lawyer Distress
3 options when intolerable environment:
Quit – leave the environment
Attempt to change the environment (more hospitable, endurable)
Change nothing in your external world and change your internal attitude toward environment (accept it, make it more palatable)
Not all solutions are equally available:
Ex: due to economy, may not be able to find another job right now
Susan Swaim Daicoff, Lawyer, Know Thyself (American Psychological Association, 2004)
ANA
Relationship between Lawyer
Distress & Competence
California Rules of Professional Conduct
Rule 3-110 Failing to Act Competently
(A) A member shall not intentionally, recklessly, or repeatedly fail to perform legal services with competence.
(B) For purposes of this rule, "competence" in any legal service shall mean to apply the 1) diligence, 2) learning and skill, and 3) mental, emotional, and physical ability reasonably necessary for the performance of such service.
ANA
Relationship between Lawyer
Distress & Competence
The level of impairment of 1 in 5 attorneys requires
clinical intervention.
Lawyer distress can be potentially devastating to
clients and society served by the legal profession.
Impact on providing effective assistance of counsel.
Susan Swaim Daicoff, Lawyer, Know Thyself (American Psychological Association, 2004)
ANA
Sources of Traumatic Exposure
Client Interviews
Police Reports
Court Reports
Social Service Reports
ALISA
Examples of Traumatic Material
Trauma
Child Abuse Domestic
Violence
Graphic or Bloody
Evidence
Housing Unfit for Human Habitation Homelessness
Lack of Resources
Human Trafficking
Sexual Assault
ALISA
Risk Factors
Coping style
Emotional avoidance
Social withdrawal
Blaming others
Personal history
Similar life experience may bring up unresolved
issues for the worker, leading to an increased sense
of vulnerability. When these feelings are transferred
onto the client, it can influence the decisions made
regarding a case
ALISA
Risk Factors
Work style
Professional boundaries
Expectations of self
Work environment
Lack of resources
Unrealistic demands
Lack of support
ALISA
Signs & Symptoms
ALISA
Vicarious Trauma: Changes in World View
Changes in Spirituality – The questioning of prior beliefs and the purpose in life
Changes in Identity – A difference in the way one conceptualizes her/his role in life
Changes in Beliefs – A shift in the way one regards safety, control, trust, esteem and intimacy Safety – Belief that there is no safe haven to protect oneself
from real or imagined threats to personal safety
Control – Diminished sense of control in the world
Trust – Inhibited ability to trust one’s own perceptions and beliefs
Esteem – For self (feelings of inadequacy in one’s own ability to help others) and for others (profound awareness of the ability for people to be cruel and for the world to be unfair)
Intimacy – Disruption in the need to feel connected to others
ALISA
McCann, I. L. & Pearlman, L. A., (1990) Vicarious Traumatization: A Framework for Understanding the Psychological Effects of Working with Victims. Journal of Traumatic Stress, 3, 131-149.
Symptoms of Vicarious Trauma
Disconnection from loved ones
Social withdrawal
Cynicism
Loss of meaning and hope
Diminished interest in self-care
Increased sensitivity to violence
ALISA
Symptoms of Secondary
Traumatic Stress
Avoidance and numbing
Efforts to avoid thoughts, feelings associated with the
trauma
Efforts to avoid activities, places or people that may
arouse recollections of the trauma
Diminished interest in activities that once brought
enjoyment, pleasure or relaxation
Feelings of detachment or estrangement from others
ALISA
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), 2000. Washington, DC: American Psychiatric Association.
Symptoms of Secondary
Traumatic Stress
Re-experiencing of the traumatic event
Intrusive recollections of the traumatic material,
including images, thoughts, perceptions and dreams
Increased arousal
Difficulty falling or staying asleep
Difficulty concentrating
Irritability and outbursts of anger
ALISA
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), 2000. Washington, DC: American Psychiatric Association.
Symptoms of Burnout Emotional Exhaustion
Depleted by the needs, demands and expectations of clients, supervisors and organizations
Cynicism Negative and detached responses to coworkers or
clients and their situations
Reduction in one’s sense of accomplishment Sense of inadequacy in resolving clients’ problems
Inability to feel productive given bureaucratic constraints and administrative demands
ALISA
Newell, J.M. & MacNeil, G.A., (2010) Professional Burnout, Vicarious Trauma, Secondary Traumatic Stress, and Compassion Fatigue: A Review of Theoretical Terms, Risk Factors, and Preventive Methods for Clinicians and Researchers. In Best Practices in Mental Health, Vol. 6, No. 2. Chicago, IL: Lyceum Books.
Behavioral Impact at Work
Avoidance of exposure to new or old traumatic
material
Intense desire to help certain clients
Perception of survivors as fragile and needing a
protector (savior)
Polarized view of others as victims or perpetrators
Thoughts and feelings of inadequacy as a
professional
Loss of hope or sense of dread when working with
certain clients
Dissatisfaction with work
ALISA
Behavioral Impact Outside Work
Client issues encroaching upon personal time
Inability to let go of work related matters
Loss of enjoyment in activities, cessation of self care activities
Loss of energy
Increased anxiety, impulsivity, and/or reactivity
Isolation
Secretive self-medication/addiction
Alcohol, drugs, work, sex, food, spending, etc.
Relational dysfunction
ALISA
Prevention &
Treatment “So now what?”
ANA
Individual Strategies
Personal
Therapeutic Self-Awareness
Connection
Healthy Habits
Coping Skills
Work-Life Balance
Education and Training
ANA
Self-Awareness
Personal History - Many people experience
trauma in their lifetimes. While trauma may not
result in PTSD or other functional impairment, it
may have relational impact that remains hidden
until purposefully exposed.
Take time to reflect
Reduce the power of your past experiences
through therapy or other proactive means
ANA
Become an Observer of Self Who are your most difficult clients?
Is there a theme???
What can you learn about yourself from this
awareness?
Recognize when you are having a strong emotional
response to a client.
Become an observer of yourself, especially when
experiencing a strong emotional reaction to a client or
client material. Pay attention to your feelings and the
behaviors and decisions that follow.
Strive to identify those interactions and relationships
that cause you to feel or act “out of character.”
ANA
Connect with People and
Purpose
People
Nurture healthy relationships and
disconnect from unhealthy relationships
Create a network of friends with diverse
careers and experiences
ANA
Create Healthy Habits
Sleep
Most people are sleep deprived which leads
to physical and psychological vulnerability
Exercise
Even 20 minutes 3 times a week makes a
difference
Diet
Do you eat at regular intervals, skip meals?
Do you eat enough fresh foods?
How about your caffeine, nicotine intake?
ANA
Develop Good Coping Skills
Prioritize Self - Make personal life a priority
Journal
Individual counseling
Create “down time”
Have Fun - Engage in activities that make you
laugh or lighten your spirits
Spend time in nature
Exercise
Create something
Spend time with friends
Play with a pet
ANA
Develop Good Coping Skills
Get away – Physically or mentally escape from
work through books, vacation or mindless
television.
Seek peer support
Relax – Find ways to spend time that are not
restricted by time or expectation
Take a nap
Lay on the beach
Meditate
ANA
Additional Options for Lawyers Lawyer Assistance Program (LAP)
Mission: support recovering attorneys in their rehabilitation and competent practice of the law, enhance public protection, and maintain the integrity of the legal profession.
Substance abuse, Mental health concerns, Stress, burnout
Business & Professions Code §6232 (d) confidentiality provision
State Bar members get a free professional mental health assessment and an opportunity to participate in the LAP without making a longer-term commitment to the program
Peer group support, individual peer support and individual counseling geared to the needs of legal professionals.
Call (877) LAP-4-HELP or go to http://www.calbar.ca.gov/Attorneys/MemberServices/LawyerAssistanceProgram.aspx for more information
ANA
Additional Options for Lawyers
The Other Bar
Network of recovering lawyers and judges
throughout the state, dedicated to
assisting others within the profession who
are suffering from alcohol and substance
abuse problems., blogs and other
resources for lawyers experiencing
vicarious trauma and burnout
ANA
Additional Options for Lawyers
Meditation
Hone traits such as focus, creativity, empathy, listening; reduce stress
“The Mindful Lawyer: Practices & Prospects for Law School, Bench and Bar”
Find or start a conference or group in your area
www.contemplativemind.org
ANA
Work-Life Balance
Build “down-time” into your day
Leave work at work, or create a “work-free
zone” at home
Unplug
Re-evaluate self-expectations
Take time to plan so that your time is used in the
most efficient manner
Learn to say “no”
Reduce case load
ANA
Education and Training Supervision / Consultation
Training focused on “traumatology” can
decrease the impact of VT & STS. Understanding
the etiology of these issues is as important as
learning effective responses to them.
Sexual Abuse
Domestic Violence
Childhood Trauma
Human Trafficking
Generational Poverty
Homelessness
ALISA
Agency Level Strategies
Caseload
Heavy client load increases risk of compassion fatigue in attorneys, but it’s not always an option to decrease your client load.
Can you vary your caseload?
If you cannot change your caseload, can you Intersperse clients with administrative tasks
Distribute the level of distress of cases, mix people who are doing well and nearer completion of their cases, or more stable cases with those who are more volatile and struggling.
1Andrew P. Levin & Scott Greisberg, “Vicarious Trauma in Attorneys,” 24 Pace L. Rev. 245 (Fall 2003) All others on slide: B. Hudnall Stamm, Ph.D.
ANA
Agency Level Strategies
Try to end the day (if at all possible) with a
positive activity so that you don’t head home
with fresh feelings of distress that you have not
had time to dissipate in the work-setting where
they belong. Otherwise, it is all too easy to
imagine that they belong in your
home/personal sphere.
B. Hudnall Stamm, Ph.D.
ANA
Agency Level Strategies Collegial and Professional-Peer Support
This may be in person, for example, a
professional “lunch” group that meets for
support
Alternatively, one can utilize technology to
create a virtual support community
Find a professional colleague in solo practice
doing similar work who can:
Listen if you are struggling
Tell you when you are struggling or when you
need to seek professional support to deal with your
feelings about work.
B. Hudnall Stamm, Ph.D.
ALISA
Prevention - A Summary
Know your own “triggers” and vulnerabilities
Understand yourself and your limitations
Maintain a work/life balance by engaging in activities that interest you
Seek support when signs of stress are prevalent and listen to others’ counsel
Delegate responsibilities when appropriate
Practice ongoing stress management techniques
Invest in opportunities that promote personal and interpersonal growth
ANA
Thank you